Smile for TOTAL HEALTH Individual Adult Dental HMO (DHMO), Maryland and Virginia A GUIDE TO YOUR DENTAL BENEFITS

Transcription

1 Smile for TOTAL HEALTH A GUIDE TO YOUR DENTAL BENEFITS 2018 Individual Adult Dental HMO (DHMO), Maryland and Virginia In the event of ambiguity, or a conflict between this summary and the Evidence of Coverage, the Evidence of Coverage shall control. Dental benefits are underwritten by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., and administered by Dominion National.

2 Discover the full-body benefits of dental coverage We bet you brush like the best of them, but did you know oral health goes beyond a great grin? By visiting a dentist regularly, you re actually doing your entire body a favor, without even stepping into a medical office. Here are a few small things dental coverage with Kaiser Permanente can do for you, your health, and the smile that expresses it all. Prevent Can clean teeth improve your overall health? Studies show that conditions like heart disease and stroke may be connected to your oral hygiene. So take a trip to the dentist you might prevent more than just cavities! Catch Dentists see what a toothbrush can t. On top of preventive care, dentists do double duty by spotting early symptoms of diabetes, cancer, and more. Support Dental checkups are also a great way to help with pre-existing conditions like diabetes that might put you at risk for gum disease. Give your brushing some healthy backup!

3 Adult Dental HMO Plan The Adult Dental HMO Plan, available to members age 19 and older, emphasizes healthy smiles through prevention and the early detection of dental problems to prevent costly procedures in the future. The combination of predictable costs, no deductibles, and no annual maximums helps you reach a state of good oral health without facing the high cost of treatment typical of many dental plans. The Adult Dental HMO Plan provides coverage for more than 250 dental procedures through one of the largest dental provider networks* in the Mid-Atlantic area. That means you have your choice of convenient private dental offices where you can receive care. You pay a $10 copayment for each preventive care office visit, which may include: Oral evaluation Topical application of fluoride Certain X-ray procedures The preventive care procedures covered in this plan account for over 65% of dental services most frequently performed for adults.* Save on restorative care Extensive care (fillings, crowns, dentures, root canals, periodontal treatment, oral surgery, etc.) is provided at cost sharing lower than the usual and customary charges for these services. A sample savings comparison chart is included in this brochure. You pay only the amount listed in the your copayment column on the savings comparison chart. When covered, specialty care services are performed by plan specialists and a different copayment will apply. For a complete copayment schedule, and a list of exclusions and limitations, please refer to your Evidence of Coverage, or you can find your plan on DominionNational.com/kaiserdentists. Choose a dentist You may select any general dentist from among our participating dental providers for yourself. Each eligible family member may use a different participating dentist. For a list of participating dentists or information about a dentist including office hours, directions, languages spoken, etc., visit DominionNational.com/kaiserdentists or call Dominion Member Services at (TTY 711), Monday through Friday, 7:30 a.m. to 6 p.m. Specialty care is also available. To receive treatment from a participating specialist, ask your participating general dentist to arrange a referral. Services received from nonparticipating dentists are not covered. Make appointments After your effective date of coverage, you can make an appointment with a participating general dentist. Make sure you bring your Kaiser Permanente medical ID card to your appointment. There is no separate dental ID card. There is virtually no paperwork and no pre-existing condition exclusions to worry about. Quality dental care You can be confident that your dentist was carefully selected to offer quality care. All participating dentists go through a strict quality assurance program developed in accordance with the National Association of Dental Plans recommendations. This process confirms that each dentist has the required credentials and has passed a thorough on-site office evaluation. * Dominion National, based on annual review of utilization data, network survey and analysis report, 3rd Quarter The Mid-Atlantic area includes Washington, DC, and parts of Maryland and Virginia. 1

4 Dedicated member service Quality customer service is an important part of any dental plan. Dominion Member Services specialists are available Monday through Friday from 7:30 a.m. to 6 p.m. to answer questions about coverage or to help you find a participating dentist. Dominion s voice response system is available 24 hours a day for information about participating dental providers in your area or to help you select a dental provider. The most up-to-date list of participating dental providers can be found online. Online self-service options Dominion provides members with secure online access to: Plan information Dentist search and dental office transfers Contact information Member services requests and general correspondence All changes are confirmed by return . Toll-free phone: (TTY 711) Fax: Mailing address: Dominion National th St., Suite 900 Arlington, VA Web: DominionNational.com/kaiserdentists SAVINGS COMPARISON partial list Procedure Average charge* Your copayment Oral examination $110 $0 Bitewing X-rays (2 films) $45 $0 Semiannual cleaning $103 $13 Complete series X-rays $146 $26 Filling (3-surface silver) $206 $64 Extraction, erupted tooth $162 $69 Crown (porcelain/metal) $1,294 $523 Root canal (anterior tooth) $708 $341 Complete denture $1,770 $697 Orthodontia is covered 2 * This information is based on Context4Healthcare s 80th percentile copayment schedule as provided and validated by Dominion National. Your copayment as provided by a participating general dentist. The schedule of dental copayments is reviewed annually and is subject to change effective January 1 of each year.

5 Schedule of Dental Copayments Adult Dental HMO Plan Only the procedures listed in the copayment schedule are covered. Procedures not shown in this list are not covered. Refer to the Evidence of Coverage for a complete description of the terms and conditions of your covered dental benefit. Copayments quoted in the Member Copayment(s) column apply only when performed by a participating general dentist or dental specialist. If specialty care is required, your general dentist must refer you to a participating specialist. NOTE: If you have any questions concerning this copayment schedule, contact Dominion for details at or toll-free at , Monday through Friday, 7:30 a.m. to 6 p.m. (TTY 711). ADA CODE BENEFITS DIAGNOSTIC/PREVENTIVE MEMBER COPAYMENT D9439 Office visit $10 D0120 Periodic oral eval established patient $0 D0140 Limited oral eval problem focused $0 D0150 Comprehensive oral eval new or established patient $0 D0160 Detailed and extensive oral eval problem focused $0 D0170 Re-evaluation limited, problem focused $0 D0180 Comprehensive periodontal eval new or established patient $36 D0210 Intraoral complete series (including bitewings) $26 D0220 Intraoral periapical first film $0 D0230 Intraoral periapical each additional film $0 D0240 Intraoral occlusal film $0 D0250 Extraoral first film and each additional film $0 D Bitewing X-rays 1 to 4 films $0 D0277 Vertical bitewings 7 to 8 films $0 D0330 Panoramic film $30 D0340 Cephalometric film $0 D0350 Oral/facial photographic images $0 D D photographic image $0 D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 3

6 ADA CODE BENEFITS MEMBER COPAYMENT D1110 Prophylaxis (cleaning) adult $0 D1110* Additional cleaning (expecting mothers or diabetics) $40 D1206 Topical fluoride varnish for moderate/high risk caries patients $0 D1208 Topical application of fluoride $0 D1310 Nutritional counseling for control of dental disease $0 D1320/30 Oral hygiene instructions $0 RESTORATIVE DENTISTRY (FILLINGS) AMALGAM RESTORATIONS (SILVER) D2140 Amalgam 1 surface $37 D2150 Amalgam 2 surfaces $46 D2160 Amalgam 3 surfaces $58 D2161 Amalgam 4 or more surfaces $69 RESIN/COMPOSITE RESTORATIONS (TOOTH COLORED) D2330 Resin-based composite 1 surface, anterior $64 D2331 Resin-based composite 2 surfaces, anterior $76 D2332 Resin-based composite 3 surfaces, anterior $90 D2335 Resin-based composite 4 or more surfaces, anterior $109 D2390 Resin-based composite crown, anterior $175 D2391 Resin-based composite 1 surface, posterior $68 D2392 Resin-based composite 2 surfaces, posterior $80 D2393 Resin-based composite 3 surfaces, posterior $93 D2394 Resin-based composite 4 or more surfaces, posterior $112 D2940 Sedative filling $37 D2951 Pin retention per tooth, in addition to restoration $22 CROWN & BRIDGE * D2510 Inlay metallic 1 surface $390 D2520 Inlay metallic 2 surfaces $390 D2530 Inlay metallic 3 or more surfaces $407 D2542 Onlay metallic 2 surfaces $423 4

7 ADA CODE BENEFITS MEMBER COPAYMENT D2543 Onlay metallic 3 surfaces $511 D2544 Onlay metallic 4 or more surfaces $511 D2610 Inlay porcelain/ceramic 1 surface $410 D2620 Inlay porcelain/ceramic 2 surfaces $410 D2630 Inlay porcelain/ceramic 3 or more surfaces $427 D2642 Onlay porcelain/ceramic 2 surfaces $439 D2643 Onlay porcelain/ceramic 3 surfaces $459 D2644 Onlay porcelain/ceramic 4 or more surfaces $459 D2650 Inlay resin-based composite 1 surface $425 D2651 Inlay resin-based composite 2 surfaces $425 D2652 Inlay resin-based composite 3 or more surfaces $425 D2662 Onlay resin-based composite 2 surfaces $429 D2663 Onlay resin-based composite 3 surfaces $429 D2664 Onlay resin-based composite 4 or more surfaces $429 D2710 Crown resin-based composite (indirect) $259 D2712 Crown 3/4 resin-based composite (indirect) $450 D2720/21/22 Crown resin with metal $470 D2740 Crown porcelain/ceramic substrate $531 D2750/51/52 Crown porcelain fused metal $495 D2780/81/82 Crown 3/4 cast with metal $457 D2783 Crown 3/4 porcelain/ceramic $469 D2790/91/92 Crown full cast metal $481 D2910/20 Recement inlay, onlay/crown, or partial coverage rest. $41 D2931 Prefabricated stainless steel crown $119 D2932 Prefabricated resin crown $135 D2950 Core buildup, including any pins $120 D2952 Cast post and core in addition to crown $181 D2954 Prefabricated post and core in addition to crown $148 D2955 Post removal (not in conjunction with endo. therapy) $101 D2980 Crown repair, by report $93 5

8 ADA CODE BENEFITS ENDODONTICS MEMBER COPAYMENT D3110/20 Pulp cap direct/indirect (excluding final restoration) $28 D3220 Therapeutic pulpotomy (excluding final restoration) $81 D3221 Pulpal debridement $87 D3310 Endodontic therapy, anterior tooth $325 D3320 Endodontic therapy, bicuspid tooth $395 D3330 Endodontic therapy, molar $488 D3333 Internal root repair of perforation defects $96 D3346 Retreat of prev. root canal therapy, anterior $356 D3347 Retreat of prev. root canal therapy, bicuspid $418 D3348 Retreat of prev. root canal therapy, molar $527 D3410 Apicoectomy/periradicular surgery, anterior $310 D3421 Apicoectomy/periradicular surgery, bicuspid (first root) $333 D3425 Apicoectomy/periradicular surgery, molar (first root) $379 D3426 Apicoectomy/periradicular surgery (each additional root) $148 D3430 Retrograde filling per root $113 D3450 Root amputation per root $202 D3920 Hemisection, not including root canal therapy $202 D3950 Canal prep/fitting of preformed dowel or post $125 PERIODONTICS D4210 Gingivectomy or gingivoplasty more than 3 cont. teeth, per quad. $265 D4211 Gingivectomy or gingivoplasty 3 or less teeth, per quad. $94 D4240 Gingival flap proc., inc. root planing more than 3 cont. teeth, per quad. $324 D4241 Gingival flap proc., inc. root planing 3 or less cont. teeth, per quad. $90 D4260 Osseous surgery more than 3 cont. teeth, per quad. $485 D4261 Osseous surgery 3 or less cont. teeth, per quad. $360 D4268 Surgical revision proc., per tooth $329 D4274 Mesial/distal wedge procedure, single tooth $308 D4341 Perio scaling and root planing more than 3 cont. teeth, per quad. $105 6

9 ADA CODE BENEFITS MEMBER COPAYMENT D4342 Perio scaling and root planing 3 or less teeth, per quad. $57 D4346 Scaling in presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation $39 D4355 Full mouth debridement $77 D4381 Localized delivery of chemotherapeutic agents $90 D4910 Periodontal maintenance $66 PROSTHETICS (DENTURES) D5110/20 Complete denture maxillary/mandibular $664 D5130/40 Immediate denture maxillary/mandibular $708 D5211/12 Maxillary/mandibular partial denture resin base $613 D5213/14 Maxillary/mandibular partial denture cast metal $722 D5221/22 Maxillary/mandibular partial denture resin base $613 D5223/24 Maxillary/mandibular partial denture cast metal $722 D5225/26 Maxillary/mandibular partial denture flexible base $722 D5281 Removable unilateral partial denture one piece cast metal $397 D5410/11 Adjust complete denture maxillary/mandibular $35 D5421/22 Adjust partial denture maxillary/mandibular $35 D5510/5610 Repair broken denture base (complete/resin) $84 D5520 Replace missing/broken teeth complete denture $84 D5620 Repair cast framework $84 D5630/60 Clasp repaired, replaced, or added $112 D5640 Replace broken teeth per tooth $84 D5650 Add tooth to existing partial denture $84 D5660 Add clasp to existing partial denture $112 D5670/71 Replace all teeth and acrylic on cast metal framework $263 D5710/11 Rebase complete maxillary/mandibular denture $253 D5720/21 Rebase maxillary/mandibular partial denture $253 D5730/31 Reline complete maxillary/mandibular denture (chairside) $152 D5740/41 Reline maxillary/mandibular partial denture (chairside) $152 D5750/51 Reline complete maxillary/mandibular denture (lab) $214 7

10 ADA CODE BENEFITS MEMBER COPAYMENT D5760/61 Reline maxillary/mandibular partial denture (lab) $214 D5810/11 Interim complete denture maxillary/mandibular $333 D5820/21 Interim partial denture maxillary/mandibular $333 D5850/51 Tissue conditioning maxillary/mandibular $75 BRIDGE & PONTICS* D6000 D6199 ALL IMPLANT SERVICES 15% DISCOUNT (inc. D0360 D0363 cone beam imaging w/ implants) D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of implant surfaces, without flap entry and closure $57 D6210/11/12 Pontic metal $481 D6240/41/42 Pontic porcelain fused metal $495 D6245 Pontic porcelain/ceramic $531 D6250/51/52 Pontic resin with metal $470 D6545 Retainer cast metal for resin bonded fixed prosthesis $233 D6548 Retainer porcelain/ceramic for resin bonded fixed prosthesis $364 D6549 Resin retainer for resin bonded fixed prosthesis $233 D6600 Inlay porcelain/ceramic, 2 surfaces $410 D6601 Inlay porcelain/ceramic, 3 or more surfaces $427 D6602 Inlay cast high noble metal, 2 surfaces $390 D6603 Inlay cast high noble metal, 3 or more surfaces $407 D6604 Inlay cast predominantly base metal, 2 surfaces $390 D6605 Inlay cast predominantly base metal, 3 or more surfaces $407 D6606 Inlay cast noble metal, 2 surfaces $390 D6607 Inlay cast noble metal, 3 or more surfaces $407 D6608 Onlay porcelain/certamic, 2 surfaces $439 D6609 Onlay porcelain/ceramic, 3 or more surfaces $459 D6610 Onlay cast high noble metal, 2 surfaces $423 D6611 Onlay cast high noble metal, 3 or more surfaces $511 D6612 Onlay cast predominantly base metal, 2 surfaces $423 D6613 Onlay cast predominantly base metal, 3 or more surfaces $511 D6614 Onlay cast noble metal, 2 surfaces $423 8

11 ADA CODE BENEFITS MEMBER COPAYMENT D6615 Onlay cast noble metal, 3 or more surfaces $511 D6720/21/22 Crown resin with metal $470 D6740 Crown porcelain/ceramic $531 D6750/51/52 Crown porcelain fused metal $495 D6780 Crown 3/4 cast high noble metal $457 D6781 Crown 3/4 cast predominantly base metal $457 D6782 Crown 3/4 cast noble metal $457 D6783 Crown 3/4 porcelain/ceramic $469 D6790/91/92 Crown full cast metal $481 D6930 Recement fixed partial denture $66 D6970 Post and core in addition to fixed part. dent. ret. $180 D6972 Prefab post and core in addition to fixed part. dent. ret. $148 D6973 Core build up for retainer, including any pins $119 D6976 Each additional indirectly fabricated post same tooth $119 D6977 Each additional prefab post same tooth $55 D6980 Fixed partial denture repair, by report $157 ORAL SURGERY D7111 Extraction, coronal remnants deciduous tooth $45 D7140 Extraction, erupted tooth or exposed root $63 D7210 Extraction, erupted tooth req. elev., etc. $127 D7220 Removal of impacted tooth soft tissue $144 D7230 Removal of impacted tooth partially bony $189 D7240 Removal of impacted tooth completely bony $227 D7241 Removal of impacted tooth completely bony, with unusual surgical complications $181 D7250 Surgical removal of residual tooth roots $136 D7251 Coronectomy intentional partial tooth removal $181 D7270 Tooth reimplant./stabiliz. of acc. evulsed or displaced tooth $211 D7280 Surgical access of an unerupted tooth $111 D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $41 9

12 ADA CODE BENEFITS MEMBER COPAYMENT D7310/20 Alveoloplasty, per quad. $135 D7510 Incision and drainage of abscess intraoral soft tissue $91 D7960 Frenulectomy (frenectomy or frenotomy) separate procedure $256 ORTHODONTICS D8090 Comprehensive orthodontic treatment adult dentition $3,658 D8660 Pre-orthodontic treatment visit $413 D8670 Periodic orthodontic treatment visit (as part of contract) $118 D8680 Orthodontic retention (rem. of appl. and placement of retainer[s]) $413 ADJUNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment of dental pain $43 D9210/15 Local anesthesia $0 D9211 Regional block anesthesia $0 D9212 Trigeminal division block anesthesia $0 D9223 Deep sedation/general anesthesia each 15-minute increment $103 D9230 Analgesia, anxiolysis, inhalation of nitrous oxide $37 D9243 IV moderate conscious sedation/analgesia each 15-minute increment $103 D9310 Consultation (diagnostic service by nontreating dentist) $43 D9910 Application of desensitizing medicament $31 D9930 Treatment of complications (post-surgical) $43 D9940 Occlusal guard, by report $298 D9950 Occlusion analysis mounted case $81 D9951 Occlusal adjustment limited $62 D9952 Occlusal adjustment complete $255 D9986 Missed appointment $50 *All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used. Only current ADA CDT codes are considered valid by Dominion National. Current Dental Terminology American Dental Association. 10

13 EXCLUSIONS AND LIMITATIONS Exclusions The following services are not covered under this plan: 1. Services which are covered under Medicare, worker s compensation, or employer s liability laws. 2. Services which are not necessary for the patient s dental health as determined by the Plan. 3. Cosmetic, elective, or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan. 4. Oral surgery requiring the setting of fractures or dislocations. 5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where, in the opinion of the Dental Administrator, such services should not be performed in a dental office. 6. Dispensing of drugs. 7. Hospitalization for any dental procedure. 8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation. 9. Replacement due to loss or theft of prosthetic appliance. 10. Procedures not listed as covered benefits under this Plan. 11. Services obtained outside of the dental office in which enrolled and that are not preauthorized by such office or the Health Plan or Dental Administrator (except for certain dental emergencies; and Continuity of Care for new Members). 12. Services related to the treatment of TMD (temporomandibular disorder). 13. Services related to procedures that are of such a degree of complexity as to not be normally performed by a Participating General Dentist. Above copayments do not apply when performed by a Dental Specialist (with the exception of orthodontics). Dental Specialists, if available, have entered into an agreement to provide dental services to members at a negotiated fee schedule. Members must directly contact the Dental Specialist to obtain fees. 14. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth as determined by the Dental Administrator. 15. The Invisalign system and similar appliances are not a covered benefit. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient s responsibility. 16. MARYLAND POLICYHOLDERS ONLY: Any bill, or demand for payment, for a service that the regulatory board determines was provided as a result of a prohibited referral. Prohibited referral means a referral prohibited by Section of the Maryland Health Occupations Article. 11

14 Limitations Covered dental services are subject to the following limitations: 1. Two (2) evaluations are covered per Plan year per patient, including a maximum of one (1) comprehensive evaluation which is limited to once in 12 months. 2. One (1) problem focused exam is covered per Plan year per patient. 3. Two (2) teeth cleanings (prophylaxis) are covered per Plan year per patient (one additional cleaning is covered during pregnancy and for diabetic patients). 4. One (1) topical fluoride or fluoride varnish is covered per Plan year per patient. 5. Two (2) sets of bitewing X-rays are covered per Plan year per patient. 6. One (1) set of full mouth X-rays or panoramic film is covered every three (3) years per patient. 7. Replacement of a filling is covered if it is more than two (2) years from the date of original placement. 8. Replacement of a bridge, crown, or denture is covered if it is more than seven (7) years from the date of original placement. 9. Crown and bridge fees apply to treatment involving five or fewer units when presented in a single treatment plan. Additional crown or bridge units, beginning with the sixth unit, are available at the provider s Usual, Customary, and Reasonable (UCR) fee, minus 25%. 10. Relining and rebasing of dentures is covered once every 24 months per patient. 11. Retreatment of root canal is covered if it is more than two (2) years from the original treatment. 12. Root planing or scaling is covered once every 24 months per quadrant per patient. 13. Scaling in presence of generalized moderate or severe gingival inflammation full mouth, after oral evaluation and in lieu of a covered D1110, limited to once per two years. 14. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. 15. Full mouth debridement is covered once per lifetime per patient. 16. Procedure Code D4381 is limited to one (1) benefit per tooth for three teeth per quadrant or a total of 12 teeth for all four quadrants per twelve (12) months per patient. Must have pocket depths of five (5) millimeters or greater. 17. Periodontal surgery of any type, including any associated material, is covered once every 36 months per quadrant or surgical site per patient. 18. Periodontal maintenance after active therapy is covered twice per Plan year, within 24 months after definitive periodontal therapy, per patient. 19. Coronectomy intentional partial tooth removal, once per lifetime. 12

15 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide no cost aids and services to people with disabilities to communicate effectively with us,such as: Qualified sign language interpreters Written information in other formats, such as large print, audio, and accessible electronicformats Provide no cost language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, call the number provided below. District of Columbia Maryland Virginia TTY 711 If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Kaiser Civil Rights Coordinator, 2101 East Jefferson Street, Rockville, MD 20852, telephone number: You can file a grievance by mail or phone. If you need help filing a grievance, the Kaiser Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at

16 Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc (Kaiser Health Plan) cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivo de la raza, color, nacionalidad de origen, edad, discapacidad o sexo. El Kaiser Health Plan no excluye a las personas o las trata de forma diferente por motivo de la raza, color, nacionalidad de origen, edad, discapacidad o sexo. Recuerde también: Nosotros les brindamos ayuda y servicios sin costo alguno a las personas que tienen unadiscapacidad que les impide comunicarse con nosotros en forma eficaz, tales como: Intérpretes calificados de lenguaje de señas Información por escrito en otros formatos, tales como letra grande, audio y otrosformatos electrónicos accesibles Brindamos servicios de idiomas sin costo alguno a personas cuyo idioma principal no sea elinglés, tales como: Intérpretes calificados Información por escrito en otros idiomas If you need these services, call the number provided below. District of Columbia Maryland Virginia Línea TTY 711 Si cree que el Kaiser Health Plan no le ha brindado dichos servicios o ha incurrido en discriminación en contra suya de otra manera por motivo de la raza, color, nacionalidad de origen, edad, discapacidad o sexo, usted puede presentar una queja ante el Kaiser Civil Rights Coordinator, 2101 East Jefferson Street, Rockville, MD 20852, número de teléfono: Puede presentar una queja por correo opor teléfono. Si necesita ayuda para presentar una queja, el Kaiser Civil Rights Coordinator estádisponible para ayudarle. También puede presentar una queja de derechos civiles ante el Departamento de Salud y Servicios Humanos de los Estados Unidos (U.S. Department of Health and Human Services), la Oficina de Derechos Civiles (Office for Civil Rights) a través del Portal de Quejas de la Oficina de Derechos Civiles, disponible en o por correo electrónico o por teléfono: Departamento de Salud y Servicios Humanos de los Estados Unidos, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Los formularios de queja están disponibles en

17 NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats, such as large print, audio, and accessible electronic formats Provide no cost language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, call (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: Kaiser Permanente, Appeals and Correspondence Department, Attn: Kaiser Civil Rights Coordinator, 2101 East Jefferson St., Rockville, MD 20852, telephone number: You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (TTY: 711). العربية (Arabic) ملحوظة : إذا كنت تتحدث العربية ف نإ خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم :TTY(.)711 Ɓa sɔ ɔ Wu ɖu (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m Ɓàsɔ ɔ -wùɖù-po-nyɔ jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ ɓɛ ìn m gbo kpáa. Ɖá (TTY: 711) ব ল (Bengali) লক য করন যদ আপদন ব ল, কথ বলত প তরন, হতল দন খরচ য় ভ ষ সহ য পদরতষব উপলব আত ফ ন কর ন (TTY: 711) 中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711)

18 توجه اگر به زب نا می باشد. با فارسی گفتگو می کنيد تسهيالت زبانی بصورت رايگان برای تماس بگيريد : (Farsi). (711 :TTY) فارسی شما فر هما Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ગજ ર ત (Gujarati) સ ચન : જ તમ ગજર ત બ લત હ, ત નન:શલ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). ह न द (Hindi) ध य न द : यहद आप ह द ब लत त आप क ललए म फ त म भ ष स यत स व ए उपलब ध (TTY: 711) पर क ल कर Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n efu, dịịrị gị. Kpọọ (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti go Diné Bizaad, saad bee áká ánída áwo dé é, t áá jiik eh, éí ná hóló, koj i hódíílnih (TTY: 711). Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). ไทย (Thai) เร ยน: ถ าค ณพ ดภาษาไทย ค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). ار دو دستياب ہ ںي خبردار : اگر آپ اردو بولتے ہيں تو آپ کو زب نا 711). :TTY) کال کر ںي کی مدد کی خدمات مفت ميں (Urdu) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi (TTY: 711).

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20 kp.org Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc MAS 1/1/18 12/31/ E. Jefferson St., Rockville, MD 20852